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PUBLIX PHARMACY #1187
STD32703 Two Spirit Health Services, Inc.
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Covered Entity Details
Entity Name
Two Spirit Health Services, Inc.
Subdivision Name
Theo Medical Dermatology
Type
Sexually Transmitted Diseases
340B ID
STD32703
Entity Address
3030 E Semoran Blvd
258
Apopka, FL 32703
Grant Number
1H25PS004342-02
Participating Start Date
7/1/2019
Last Recertification Date
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #1187
Pharmacy Address
2783 ELKCAM BLVD
DELTONA, FL 32738
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David Baker-Hargrove, President/Co-CEO
(321) 800-2922
Contract Pharmacy Representative
Publix
Dain Rusk, Vice President
(863) 688-1188
Signed By Date
7/15/2019
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